Discuss at least two (2) ways that your selected articles impact your patient teaching.

Topic: effect of Vaping among teenagers

1-Describe your topic and why you selected it.

2-How do the articles you selected impact the evidence-based practice in your chosen topic?

3-Discuss at least two (2) ways that your selected articles impact your patient teaching.

4-Be sure to present your articles using APA 7th edition formatting.

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Tobacco Use Insights Volume 13: 1–15 © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1179173X20945695

Introduction Current (past 30-day) vaping among U.S. adolescents has increased dramatically in recent years.1,2 Rates almost doubled from 2017 (11.0% of 12th graders) to 2018 (20.9%), the largest substance use increase ever observed in the 44-year history of the national Monitoring the Future study.1 Vapes have been the most commonly used tobacco product among adolescents since 2014,2 and more than 5 million middle and high school students were current vape users in 2019.3 These dramatic increases have offset reductions in cigarette smoking, fueling an overall increase in adolescent current tobacco use.1,4

This explosion of vaping is concerning because of the risks associated with adolescent vape use. Adolescents who vape are more likely than non-users to initiate cigarette smoking and escalate smoking among those who have already experimented with cigarettes,5-11 though this association may be due to shared risk factors for vaping and smoking.12 Researchers are beginning to understand the chemical constituents and health

implications of vape juice and aerosols, which include carcino- gens and irritants.8,13-17 Although long-term health effects are unknown, vaping may be associated with short-term risks including respiratory symptoms, asthma, and bronchitis among adolescents.8,18,19 In addition, nicotine exposure affects adoles- cent brain development, leading to long-term cognitive issues including memory and attention impairment.20-22

Despite the alarming increase, teens who vape remain a minority of the adolescent population.3 Little is known about which youth are at the greatest risk beyond demographic descriptions, leaving public health interventionists with a lim- ited understanding of who should be prioritized in prevention efforts. Current vaping is more prevalent among male, non- Hispanic White, higher socioeconomic status, and lesbian, gay, and bisexual adolescents and young adults.23-27 In addition, young current vape users often have friends and family mem- bers who vape or who accept vaping,28 and use other substances including cigarettes and marijuana.29-31

The Vaping Teenager: Understanding the Psychographics and Interests of Adolescent Vape Users to Inform Health Communication Campaigns

Carolyn Ann Stalgaitis , Mayo Djakaria and Jeffrey Washington Jordan Research Department, Rescue Agency, San Diego, CA, USA.

ABSTRACT

BACkgRoUnd: Adolescent vaping continues to rise, yet little is known about teen vape users beyond demographics. Effective intervention requires a deeper understanding of the psychographics and interests of adolescent vape users to facilitate targeted communication campaigns.

MeTHodS: We analyzed the 2017-2018 weighted cross-sectional online survey data from Virginia high school students (N = 1594) to iden- tify and describe subgroups of adolescents who vaped. Participants reported 30-day vape use, identification with 5 peer crowds (Alterna- tive, Country, Hip Hop, Mainstream, Popular), social prioritization, agreement with personal values statements, social media and smartphone use, and television and event preferences. We compared vaping rates and frequency by peer crowd using a chi-square analysis with follow- up testing to identify higher-risk crowds and confirmed associations using binary and multinomial logistic regression models with peer crowd scores predicting vaping, controlling for demographics. We then used chi-square and t tests to describe the psychographics, media use, and interests of higher-risk peer crowds and current vape users within those crowds.

ReSUlTS: Any current vaping was the highest among those with Hip Hop peer crowd identification (25.4%), then Popular (21.3%). Stronger peer crowd identification was associated with increased odds of any current vaping for both crowds, vaping on 1 to 19 days for both crowds, and vaping on 20 to 30 days for Hip Hop only. Compared with other peer crowds and non-users, Hip Hop and Popular youth and current vape users reported greater social prioritization and agreement with values related to being social and fashionable. Hip Hop and Popular youth and current vape users reported heavy Instagram and Snapchat use, as well as unique television show and event preferences.

ConClUSIonS: Hip Hop and Popular adolescents are most likely to vape and should be priority audiences for vaping prevention cam- paigns. Findings should guide the development of targeted health communication campaigns delivered via carefully designed media strategies.

keywoRdS: E-cigarette, vaping, adolescent, psychographics, peer crowd, personal value, social media, health communication

ReCeIVed: November 26, 2019. ACCePTed: June 17, 2020.

TyPe: Original Research

FUndIng: The author(s) received no financial support for the research, authorship, and/or publication of this article.

deClARATIon oF ConFlICTIng InTeReSTS: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

CoRReSPondIng AUTHoR: Carolyn Ann Stalgaitis, Rescue Agency, 2437 Morena Blvd., San Diego, CA 92110, USA. Email: Carolyn@RescueAgency.com

945695TUI0010.1177/1179173X20945695Tobacco Use InsightsStalgaitis et al research-article2020

https://uk.sagepub.com/en-gb/journals-permissionsmailto:Carolyn@RescueAgency.com

2 Tobacco Use Insights

Audience psychographics move beyond demographics to provide health communicators with critical insights about val- ues, identities, and interests that can inform effective messag- ing and campaign strategies.32-35 In addition, these insights are critical for the effective planning and execution of modern digital media campaigns that rely on interest-based targeting to deliver digital advertisements to the intended audience.36 Past studies describing ever and current vape users have typi- cally focused on vaping attitudes and beliefs,37-40 or have used psychographics and motivations to segment adult, but not ado- lescent, vape users into discrete subgroups.41,42 Only a few studies have examined the psychographics of adolescent or young adult vape users, revealing that novelty-seeking, sensa- tion-seeking, and lower social conservatism are generally asso- ciated with ever and current vaping in these populations.27,43,44 From this basis, we seek to expand health communicators’ understanding of the psychographics, identities, media use, and interests of adolescent current vape users to inform the devel- opment of effective vaping prevention campaigns.

Knowing which adolescents vape, what other substances they use, what they care about, and what influences them is crucial to addressing adolescent vaping. Commercial market- ing, including vape marketing, relies on audience segmentation to identify population subgroups with shared desires and needs for whom a tailored brand can be built and marketed via tar- geted media channels.45 In health communications, a similar approach is necessary to counter industry marketing by identi- fying adolescent subgroups at the greatest risk for vaping, developing targeted campaigns that appeal to their shared val- ues, beliefs, and interests, and delivering campaign content via specific media channels and strategies to ensure the target audience is reached.45 Health campaigns designed around the psychographics of their target audiences are effective,45-47 but this approach requires a clearly defined audience with unique characteristics for whom appealing content can be tailored. Importantly, campaigns must both tailor messaging (by select- ing messaging that caters to audience preferences, values, and interests to capture attention and increase persuasion) and tar- get media delivery (by selecting highly specialized media chan- nels and using state-of-the-art ad-targeting technologies) to effectively reach their target audiences in the modern, cluttered media environment.47 Although much is known about the demographics of adolescent vape users, health educators lack crucial information about their values, influences, and interests that is necessary to define an audience and deliver effective, targeted communications.

To fill this gap, we used online survey data to describe the risk profile, psychographic characteristics, and interests of ado- lescent current vape users in a single U.S. state. We had 2 pri- mary objectives: to identify potential target audiences for adolescent vaping prevention campaigns and to describe the psychographics, media use, and interests of these higher-risk youth to inform campaign planning. First, we sought to define potential target audiences by applying a peer crowd audience

segmentation approach. Peer crowds are macro-level subcul- tures with shared interests, values, and norms47,48 which are associated with adolescent and young adult health behaviors49-57 and have served as the basis for targeted health interventions.58-64 For example, the Commune campaign target- ing Hipster peer crowd young adults resulted in reductions in cigarette smoking associated with stronger anti-tobacco atti- tudes among those recalling the campaign,58,62 whereas engage- ment with the Down and Dirty campaign was associated with stronger anti-chewing tobacco attitudes and lower odds of cur- rent use among Country peer crowd teens.61 In this study, we examined vaping behavior for 5 adolescent peer crowds previ- ously established in the literature: Alternative (counterculture, value creativity and uniqueness), Country (patriotic, value hard work and being outdoors), Hip Hop (confident, value over- coming struggles and proving themselves), Mainstream (future-oriented, value organization and stability), and Popular (extroverted, value socializing and excitement).47,49,50,52,54,55,61 After identifying the highest risk peer crowds, we sought to create a profile of these audiences by examining their broader health risk profiles, psychographics (social prioritization and personal values), digital behaviors (social media and smart- phone use), and interests (television shows and events). With this information, we aimed to identify and describe segments of adolescents most in need of targeted vaping interventions to provide clear guidance for health message development and media targeting.

Methods Sample and design

We collected cross-sectional online survey data from high school students ages 13 to 19 living in the U.S. state of Virginia (N = 1594). Participants were recruited from November 2017 to January 2018 using paid Instagram and Facebook advertise- ments that directed interested individuals to a screener to determine eligibility (13-19 years old, current high school stu- dent, and Virginia resident). Eligible youth were invited to par- ticipate in the full survey and provided electronic assent (ages 13-17) or consent (ages 18-19). We delivered a parental opt- out form via email for participants ages 13 to 17. Qualified participants who completed the full survey received a US$10 electronic gift card incentive. We implemented numerous fraud prevention and detection measures to maximize data integrity, including concealing eligibility criteria during screening, col- lecting email addresses to prevent duplicate completions, and reviewing responses for inconsistencies. Chesapeake IRB approved the study (No. Pro00023204).

Measures

To address our research objectives, we examined participant demographics; current vaping, tobacco, and other substance use; peer crowd identification; 2 psychographic measures, namely, social prioritization65 and personal values; social media

Stalgaitis et al 3

and smartphone use; and television show and event preferences.

Demographics. Participants provided their birthdate, from which we calculated their age. Participants also indicated their gender (male, female) and race/ethnicity (Hispanic, non-His- panic White, non-Hispanic Black, non-Hispanic Asian-Pacific Islander, and non-Hispanic other including multiracial and American Indian or Alaska Native).

Past 30-day vape use. Participants reported the number of days in the past 30 days on which they used e-cigarettes or vapes, with response options of 0, 1 or 2, 3 to 5, 6 to 9, 10 to 19, 20 to 29, and all 30 days. To mirror commonly reported statistics, we examined both any current vaping (1-30 days) and frequency of vaping defined as occasional use (1-19 days) or frequent use (20-30 days).66

Past 30-day tobacco and substance use. Participants also reported the number of days in the past 30 days on which they used cigarettes; cigars, cigarillos, and little cigars (cigar products); smokeless tobacco; hookah; alcohol; marijuana; and prescrip- tion medication without a prescription. Those who reported any past 30-day use were considered current users of that item.

Peer crowd identif ication. Participants completed Rescue Agency’s I-Base Survey®, a photo-based tool that measured identification with 5 peer crowds: Alternative, Country, Hip Hop, Mainstream, and Popular. The I-Base Survey has identi- fied consistent patterns of peer crowd prevalence and health risks in adolescents across the United States.49-52,55,57,61,64 In brief, participants viewed a grid of 40 photos of unknown female adolescents and selected 3 who would best and 3 who would least fit with their main group of friends; they then repeated the process with male photos. Photos were presented in random order to each participant to reduce order effects, and represented a mix of races/ethnicities and peer crowds deter- mined through prior qualitative research. Participants earned positive points for the peer crowds of photos selected as the best fit and negative points for those selected as the least fit, resulting in a score ranging from –12 to 12 for each of the 5 crowds. For analyses, we assigned participants to each crowd with which they had at least some identification, defined as a score of 1 or more on the I-Base Survey for that crowd. Partici- pants could be assigned to more than 1 peer crowd as they could score positively for multiple crowds.

Social prioritization index. Participants completed the social prioritization index (SPI), a validated measure of the degree to which an individual places importance on their social life that is associated with young adult cigarette use.58,59,65 The SPI included 13 questions: 8 items wherein participants selected 1 response that best described them from a pair (up for anything/ pick and choose what to do, outgoing/low-key, center of

attention/lay low, street smart/book smart, partier/studier, wing it/plan it out, the carefree one/the responsible one, in a picture I . . . strike a pose/smile big); 3 true or false items (In groups of people, I am rarely the center of attention; I have considered being an entertainer or actor; I can look anyone in the eye and tell a lie with a straight face); 1 item asking how many nights they went out for fun in the past week (0-1, 2-3, 4-5, 6-7 nights); and 1 item asking how late they typically stayed out when they went out for fun (9:59-10:59 pm, 11:00 pm-12:59 am, 1:00- 2:59 am, 3:00 am or later). To calculate the SPI score (range: 0-17), participants received 1 point for each socially oriented selection for the 8 descriptive pairs and 3 true/false questions, and received 0 points for selecting 0-1 nights per week or 9:59- 10:59 pm, 1 point for 2-3 nights per week or 11:00 pm-12:59 am, 2 points for 4-5 nights per week or 1:00-2:59 am, and 3 points for 6-7 nights per week or 3:00 am or later.

Personal values. Participants viewed 26 personal values state- ments (e.g., I think it is more important to live in the moment than focus on the future) and rated each on a 5-point Likert- type scale from 1 (strongly disagree) to 5 (strongly agree).

Past 7-day social media use. Participants reported if they had consumed or created content on 6 social media platforms in the past 7 days: Facebook, Instagram, Twitter, Tumblr, Snapchat, and Pinterest.

Lifetime smartphone use. Participants were asked if they had a smartphone, and if so, if they had ever used their smartphone to engage in 9 different activities (e.g., listen to an online radio or a music service such as Pandora or Spotify; watch movies or TV shows through a paid subscription service like Netflix).

Television show preferences. Participants selected all television shows they regularly watched from a list of 24 broadcast and streaming shows popular with youth (e.g., 13 Reasons Why, Ridiculousness).

Event preferences. Participants selected all events they regularly attended from a list of 25 leisure time events youth might attend (e.g., sports games, high school dances).

Statistical analysis

Respondents were required to complete the survey, so no data were missing. Data were weighted to the gender, race/ethnicity, and urban/rural demographics of Virginia teens for all analy- ses. As a first step, we ran weighted and unweighted frequen- cies and means for demographic measures.

To address our first objective of identifying which adoles- cents were at the greatest risk, we used chi-square tests to com- pare the rates of current vaping and vaping frequency among those who did and did not identify with each crowd, using follow-up z tests with Bonferroni correction to identify specific

4 Tobacco Use Insights

significant differences. To confirm that associations persisted while controlling for demographics, we ran separate binary and multinomial logistic regression models for each peer crowd, with a single peer crowd’s score (range: –12 to 12) predicting odds of current vaping, or of occasional or frequent vaping, while controlling for age, gender, and race/ethnicity. We also ran binary logistic regression models for each crowd to predict odds of any current cigarette, cigar product, smokeless tobacco, hookah, alcohol, and marijuana use, and any current prescrip- tion medication misuse, to understand the broader risk profile of the peer crowds. We ran separate models for each peer crowd to avoid multicollinearity associated with including all 5 scores in a single model.

After identifying 2 peer crowds at elevated risk for vaping, we addressed our second objective of developing interest-based profiles of these potential target audiences by describing their psychographics (SPI and personal values), social media and smartphone use, and television and event preferences. We first compared frequencies and means for those who did and did not identify with the 2 crowds of interest, using chi-square tests and t tests to identify significant differences. Then, within the 2 peer crowds, we compared frequencies and means between current vape users and non-users, using chi-square tests and t tests to identify significant differences. This approach allowed us to identify the characteristics of the 2 peer crowds of interest to inform campaign content and media targeting, as well as to hone in on psychographics and interests that specifically char- acterized current vape users within the higher-risk crowds. Due to the relatively small subset of participants who were fre- quent vape users, we focused on any current use to improve the reliability of results. Tables present items that differed signifi- cantly between groups in at least 1 analysis and had endorse- ment rates above 5.0%.

Results The weighted mean age of the sample was 16.47 years, and about half identified as female (50.8%) and as non-Hispanic White (55.3%) (Table 1). The most common peer crowd iden- tifications were Popular (63.1%) and Mainstream (62.6%). Race/ethnicity and gender breakdowns differed by crowd (Supplemental Appendix Table 1).

Consistent with 2018 National Youth Tobacco Survey results,2 20.6% of Virginia high school students in our sample currently vaped (Table 2). A significantly greater proportion of those with any Hip Hop peer crowd identification currently vaped (25.4%) than those with no Hip Hop identification (18.0%, P < .001). In binary logistic regression models using each peer crowd score (–12 to 12) to predict odds of current vaping while controlling for demographics, a 1-point increase in the Popular score was associated with a 4% increase in odds of current vaping, whereas a 1-point increase in the Hip Hop score was associated with a 10% increase.

Further differentiating current vape users in the sample, 17.0% were occasional vape users (1-19 days in the past 30 days)

and 3.7% were frequent users (20-30 days). Those with any Hip Hop identification reported higher rates of occasional vaping (21.2%) than others (14.6%, P < .05). Although rates of frequent vaping did not differ significantly for any peer crowd, stronger Hip Hop identification was associated with greater odds of both occasional and frequent vaping. Stronger Popular identification was associated with greater odds of occasional vaping only. In addition, stronger Hip Hop identification was associated with greater odds of current cigarette, cigar product, hookah, alcohol, and marijuana use, whereas stronger Popular identification was associated with lower odds of use for many products.

Based on the chi-square tests and logistic regression results, we identified the Hip Hop and Popular peer crowds as being at elevated risk for vaping. We then characterized the psycho- graphics (Table 3), social media and smartphone use (Table 4), and interests (Table 5) of Hip Hop and Popular youth in gen- eral, as well as Hip Hop and Popular current vape users in particular.

Overall, Hip Hop participants were social, trendy individu- als interested in hip hop/rap music and sports. Compared with those with no Hip Hop identification, Hip Hop youth had higher SPI scores, in particular describing themselves as par- tiers, street smart, and carefree (Table 3). Hip Hop youth more often agreed that they make decisions quickly, are fashionable, are social people with lots of friends, and are tougher than most people. In contrast, they less often agreed that they are patri- otic, good students, care what others think about them, care about keeping their bodies free from toxins, and follow the rules. A greater proportion of Hip Hop youth used Snapchat in the past week and used their smartphones to look up sports scores or analyses than those with no Hip Hop identification (Table 4). Many TV shows more often endorsed by Hip Hop youth revolved around hip hop/rap musical interests, such as Love & Hip Hop, The Rap Game, and Wild ’N Out (Table 5). Similarly, Hip Hop youth more often indicated that they regu- larly attend hip hop concerts and dance clubs than others, as well as basketball and football games.

Characteristics of vape users within the Hip Hop peer crowd largely reflected an amplification of the broader crowd’s profile. Hip Hop vape users had higher SPI scores than non- users within the crowd, and they described themselves as par- tiers, street smart, carefree, and up for anything (Table 3). They more often agreed that they are fashionable, use their clothes to express their identity, and are tough, and less often agreed that they follow the rules, follow tradition, and care about keeping their bodies free from toxins than non-users. A greater propor- tion of Hip Hop vape users reported using Snapchat, Instagram, and Twitter in the past week than non-users (Table 4). Hip Hop vape users also more often reported using their smart- phones to look up sports scores and analyses, stream music, and make video calls than non-users. Hip Hop vape users more often reported watching 2 cartoon shows, The Boondocks and Bob’s Burgers, than non-users (Table 5). Similar to the overall

Stalgaitis et al 5

crowd, a greater proportion of Hip Hop vape users indicated that they attend dance clubs, hip hop concerts, basketball games, and football games than non-users.

Popular youth shared some characteristics with Hip Hop youth, but also differed in key ways. Although Popular and Hip Hop youth both reported higher SPI scores than others, the specific SPI items they endorsed often differed (Table 3). Though both Hip Hop and Popular youth described them- selves as partiers, Popular youth also described themselves as the center of attention, outgoing, and up for anything, which were not significant in Hip Hop analyses. Similar to Hip Hop youth, Popular youth more often agreed that they are fashion- able and are social people with lots of friends. However, Popular youth also more often agreed that they care about being good students, keeping their bodies free from toxins, and being patriotic, items with which Hip Hop youth less often agreed. Popular youth also more often agreed that family is important,

that they try to follow tradition, and that they are religious than other youth. Popular youth more often reported using Instagram, Snapchat, and Twitter than other youth and more often used their smartphones to look up sports scores or analy- ses and to stream music or video content (Table 4). Compared with others, Popular youth more often reported watching teen dramas, including 13 Reasons Why, Jane the Virgin, Pretty Little Liars, and Riverdale (Table 5). Sports were favored by Popular youth, as they more often reported attending basketball, foot- ball, baseball, and soccer games than others. They also more often reported attending church events, community service events, high school dances, and pop and country music concerts.

Popular vape users shared many traits with the broader Popular crowd as well as with Hip Hop vape users. Similar to Hip Hop vape users, Popular vape users reported higher SPI scores than non-users, describing themselves as outgoing,

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